Safety of care

Improving patient safety and reducing risks

Accepting new patients: The key to effective practice management

Originally published September 2018
18-20-E

An elderly woman is having a casual conversation with her neighbour who is a practising family physician, and says she is dissatisfied with the care she is receiving at a nearby walk-in clinic. She asks the physician whether he is able to accept her as a new patient in his practice. The patient briefly describes her medical conditions, which require ongoing treatment and monitoring. The physician replies that he is not currently accepting new patients, though he does maintain a wait list of prospective patients. She asks him to put her on the list, despite being advised the wait could be at least six months. Feeling sympathetic to his neighbour, the following day the physician instructs his office assistant to put this individual near the top of the wait list in an effort to reduce her wait time. Is this action appropriate, given the circumstances?

Timely access to physician care is a challenge for Canadians in many parts of the country, leaving physicians to make the sometimes-difficult decision about whether or not to accept new patients. Faced with already heavy workloads, physicians face the moral dilemma of possibly turning away people seeking care in order to maintain a sustainable and well-managed practice.

Indeed, many physicians—whether they are in primary care practice such as family physicians, or consultant physicians who typically only accept patients via referrals—encounter this challenge. Differences in how these two groups accept new patients reflect the different nature of the care provided, and in this article we focus on the former group—those in primary care practice.

While there are some variations, regulatory authority (College) policies on accepting new patients share many similar elements that are grounded in physicians’ ethical responsibilities. Physicians should be mindful of these elements when they receive a request for ongoing clinical care from an individual with whom there is no existing doctor-patient relationship, including:

  • urgency and need
  • scope of practice and clinical competence
  • discrimination
  • wait lists

Urgency and need

Physicians are generally not obligated to treat any individual seeking non-urgent or non-emergent care. That said, physicians who receive a request to accept a new patient should consider whether the individual requires emergency care. While providing emergency treatment does not necessarily imply the formation of an ongoing doctor-patient relationship, providing such care when needed is consistent with the CMA Code of Ethics, which advises physicians to "provide whatever appropriate assistance you can to any person with an urgent need for medical care."1

The Colleges offer guidance that is more specific in this area. The College of Physicians and Surgeons of British Columbia, for example, states that "in medically emergent or urgent situations, physicians are expected to provide whatever medical care is appropriate, taking into account the physician’s scope of practice and available options such as access to specialist consults."2

In some circumstances, it may be appropriate for physicians to prioritize access to care for individuals with greater needs or complex conditions. The College of Physicians and Surgeons of Ontario (CPSO) advises that physicians should use their professional judgment to determine whether prioritization based on need is appropriate, taking into account social factors that may influence the person’s health outcomes such as the individual’s housing, food security, employment, and income.3

Scope of practice and clinical competence

Physicians accepting new patients should not refuse individuals solely due to the presence of a complex or chronic health problem or if an individual requires more time than another patient with fewer medical needs. Nevertheless, if the individual’s care needs are not within the physician’s scope of practice or clinical competence, this would generally be considered grounds for refusing a prospective patient.3

Discrimination

Physicians are bound by the human rights legislation of their province or territory. As well, the CMA Code of Ethics states that in providing a medical service, providers are not to "discriminate against any patient on such grounds as age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status."1 Nevertheless, "this does not abrogate the physician’s right to refuse to accept a patient for legitimate reasons."1

If refusing a prospective patient’s request, physicians should consider the impact of such a refusal on the patient. Some individuals may interpret a refusal as discrimination, even when this was not the physician’s intention. For this reason, it is important to clearly and respectfully communicate the reasons for a refusal to the individual making the request, thereby dispelling possible perceptions of discrimination.

Wait lists and patients’ family members

If a physician is accepting new patients, the principle of first-come, first-served should generally apply for patients in a similar situation.4 This also means that prospective patients on a wait list should be accepted into a practice in the same order in which they were added to the list. When using a wait list, clearly communicating the expected waiting period to new prospective patients helps manage expectations and diffuse potential misunderstandings.

It is generally justified to accept into a practice members of existing patients’ families even when a physician is not otherwise accepting new patients. Caring for patients’ family members may provide a broader view of family history, which could contribute to better health outcomes.3

The bottom line

  • The decision to either accept or refuse a new patient should always be made in good faith and in keeping with your College’s policy on accepting new patients.
  • Your decision may depend on such factors as whether your practice is accepting new patients and whether you are qualified to provide the care requested or expected to be needed.
  • If you decide to not provide treatment or not accept a new patient to your practice, the decision should be made in non-emergency situations only and in a way that applies to all prospective patients equally.
  • Discuss your decision to not accept a new patient with the individual respectfully and honestly, and document this in your files.

Physicians who are unsure about what to do when requested to provide treatment to an individual where there is no existing doctor-patient relationship may contact the CMPA for individual advice.

In our introductory vignette, while the patient clearly needed to be followed by a physician, her immediate needs were not urgent. By placing her ahead of others on the wait list, other patients who had been waiting longer and those with more serious problems would be adversely affected. In this example, having determined the prospective patient’s needs and current situation, the best approach might have been to add her to the wait list on a first-come, first-served basis, or if possible to offer a referral to another physician.




References

  1. Canadian Medical Association [Internet]. Ottawa (CA): CMA; 2004 (reviewed 2018 March). CMA code of ethics [cited 2018 May 9]; [1 screen]. Available from: https://www.cma.ca/En/Pages/code-of-ethics.aspx
  2. College of Physicians and Surgeons of British Columbia [Internet]. Vancouver (CA): CPSBC; 2012 Nov. Professional Standards and Guidelines, Access to Medical Care [cited 2018 May 9]; [3 screens]. Available from: https://www.cpsbc.ca/files/pdf/PSG-Access-to-Medical-Care.pdf
  3. The College of Physicians and Surgeons of Ontario [Internet]. Toronto (CA): CPSO: 2008 Nov (updated 2017 May). Accepting New Patients [cited 2018 May 9]; [4 screens]. Available from: http://www.cpso.on.ca/Policies-Publications/Policy/Accepting-New-Patients
  4. College of Physicians and Surgeons of Alberta [Internet]. Edmonton (CA): CPSA: 2010 Jan 1 (reissued 2015 Jun 11). Standard of Practice, Establishing the Physician-Patient Relationship [cited 2018 Jun 4]; [2 screens]. Available from: http://www.cpsa.ca/standardspractice/establishing-physician-patient-relationship/

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.